Patient Autonomy, Family Paternalism, and Doctor’s Responsibility in Medical Decisions Concerning End of Life: A Legal and Empirical Analysis of the Hospice-Palliative Care Act
|關鍵字:||安寧緩和醫療條例;維生醫療;病人自主;醫師專業責任;無效醫療;The Hospice-Palliative Care Act;Life-Sustaining Treatment;Patient Autonomy;Doctor’s Responsibility;Medical Futility|
In Taiwan, terminally ill patients are entitled to refuse life-sustaining treatment after the Hospice-Palliative Care act enacted in 2000. By formulating the act, government hopes that terminally ill patient can achieve a "good death". After enacted, the Act has been amended for 3 times and mainly focused on lawfully withdrawing life-sustaining interventions by third parties.The purpose of this study is to examine how patients’ right to refuse life-sustaining treatment be implemented under the Hospice-Palliative Care Act. By literature review and qualitative research, the author would like to investigate the international development of end-of-life issues and the legal response of Taiwan, the exercise of patient’s right to refuse life-sustaining treatment in current clinical practice, and the needed improvement. By conducting qualitative interviews with 14 intensive care unit physicians from 8 hospitals in Taiwan, the author found that patient’s wishes were rarely known for mostly being incompetent with no advance directives, thus it was mainly the patient’s family to make surrogate decision. Though the Act needs only one legal family surrogate to make decisions, if no consensus has been achieved among influential family members (not necessarily be qualified legal surrogate), the provision of life-sustaining treatment would not end. Since consensus among family members was the only rule for surrogate decision making process, health care provider might find inappropriate considerations, such as personal emotions and financial interests. According to the amendment of Hospice Palliative Care Act in 2013, health care provider could also make surrogate decisions based on patients’ best interest if no qualified family members could be find. Health care provider might consider whether the patient is curable, the quality of life and the burden of treatment is acceptable when making the judgment. For the reason that health care providers thought differently between “withdraw” and “withhold”, and interpreted the law conservatively, the result indicated that the new amendment would make little difference to current practice. In some cases, health care providers might identify surrogate’s request for life sustaining treatment as medically inappropriate for prolonging process of dying, being pointless, bringing pain or ultra burdens, bring no improvement and minimum chance of success. Although the interventions might make the patient suffered or consume medical resources, due to legal, psychological, social, cultural, and economical considerations, if the conflicts couldn’t be solved through communication or temporary attempt, these interventions would often be provided. As a result, the implementing rate of life-sustaining treatment became so high. Many health care providers agree with BNHI’s restriction as a solution, others suggest that health care providers should have the right to deny inappropriate request from surrogates. In order to protect patient’s right to refuse life sustaining treatment, the author found it necessary to broaden the scope of application of the Hospice-Palliative Care Act. Patients should be authorized to refuse life-sustaining treatment not only for prolonged dying process but also for unacceptable quality of life. It was also necessary to set implicit standard for durable power of attorney and surrogate to comply with when patient is incompetent. Patient’s wish should be the primary consideration, then his/her best interest. Though health care provider also could make surrogate decisions when patient was incompetent without any advance directive or qualified legal surrogate, the author found this new amendment might conflict the basis of the Hospice-Palliative Care Act, which is patient autonomy. Therefore, the amendment should be deleted. Based on professional integrity, the author also suggested health care providers to assist patient or their attorney and surrogate in decision-making by explaining medical considerations and providing recommendation, health care providers should also ask for second opinion whenever attorney or surrogate’s decision conflicts patient’s wish or best interest. Although BNHI’s restriction for “futile” treatments did reduce inappropriate use of life-sustaining treatment, the implication of medical futility should not be confused with rationing. Under medical futility circumstances, the health care provider no longer have absolute duty to follow individual’s choice or even have the duty not to comply with the request if the treatment carry no benefit or benefit with ultra burden. The theory had been provided to deal with the conflicts between professional judgment and personal request on the basis of nonmaleficience and beneficence, not medical resource allocation. To clarify the differences, BNHI should limit inappropriate use of life-sustaining treatment by other rationing standards. The author also encouraged health care providers continue to discuss the definition and ethical implication of medical futility, to help general public recognize the limit of life-sustaining treatments.